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David W. Kim, MD, Facial Plastic Surgery

MORE DETAILS ABOUT REVISION RHINOPLASTY

What are the types of problems revision rhinoplasty can correct?

In essence, revision rhinoplasty, or corrective nose surgery, seeks to correct problems caused by a previous nose surgery. The following are some of the problems, providing examples of the technical mistakes and resultant deformities. In many cases, more than one type of complication exists within a given revision rhinoplasty nose.

Types of Rhinoplasty Complications

Asymmetric structural modification (e.g. bone cut or cartilage sutures)
Malpositioned cartilage graft
Malpositioned implant
Asymmetric nose
Palpable or visible graft
Palpable or visible implant (possible infection)
Error of omission (Failure to execute a needed step)
Persistent original problem
Failure to restabilize structures which have been weakened during surgery, including,
- the nasal base
- the nasal bridge
- the outer wall
Drooping nasal tip
Pinched nose (bridge), internal nasal obstruction
Pinching of the nasal tip, nasal obstruction
Excessive excision (over-aggressive reduction of the nose)
Lower edge of the septum
Nasal tip cartilages
Nasal bridge
Nostril base
Short nose, up-turned nose, retracted columella
Tip irregularity, tip collapse, nasal obstruction
Scooped dorsum, ski-sloped nose, nasal obstruction
Overly narrow nostrils, slit-like nostrils, nasal obstruction
Gross error of judgment – possible severe deformity

How is the surgery done?

Dr. Kim uses an open or external approach during revision rhinoplasty. This is because the complexity of revision cases generally requires the additional exposure and visualization provided by this approach. For the correction of isolated minor problems, an internal approach may be possible.

Once exposure is achieved, the specific maneuvers used depend on the type of problems needing correction. Common problems requiring revision rhinoplasty surgery are outlined below.

Irregularity of the nasal bridge

Most commonly, this problem arises after contour irregularities are created along the bony and/or cartilaginous dorsum. Such problems may be addressed through rasping of the bone or shaving of the dorsal cartilage. If there are areas of deficiency due to over-excessive reduction, augmentation grafting with cartilage or soft tissue grafts may be of benefit.

Polybeak (rounded tip)

A polybeak refers to an abnormality seen on the profile view in which the tip of the nose is less projected (sticks out less) than the bridge above it. This causes a rounded appearance to the tip with an associated lack of definition. One cause of this problem is the failure to adequately reduce an overly high bridge. In such noses, the profile view of the bridge looks outwardly curved, or convex.

The overall "hook" shape of the nose can be corrected if the bridge is reduced and/or the nasal tip is brought forward further. When done correctly, this will result in a bridge that appears straight or slightly concave (inwardly curved). If these maneuvers do not fully correct the problem, an outward curvature (convexity) may persist after surgery.

Because this deformity is caused by inadequate previous reduction of the bridge and tip cartilages, this type of problem is called a "cartilaginous polybeak". Correction during revision surgery requires either further reduction of the bridge or elevation/projection of the nasal tip.

Another type of polybeak deformity is caused by excessive excision of the cartilage of the nasal bridge, particularly in patients with thick, stiff skin. In this situation, the skin is unable to redrape tightly down onto the cartilage infrastructure which has been aggressively reduced (lowered). A gap then results between the stiff skin envelope and the cartilage. This void eventually fills with scar tissue, resulting in the so called "soft-tissue polybeak". Correction of this problem is difficult and requires primarily elevating and repositioning the nasal tip structures into a more projected position to stretch into the thickened soft tissue envelope. This restores the normal relationship between the tip of the nose and the bridge above it so the profile will look straighter.

Pinching of the nasal bridge

The middle one-third of the nose is created by the two mirror-image "upper lateral" cartilages and the nasal septum between them. The septum forms the vertical structural wall that supports the nasal bridge. Each upper lateral cartilage (ULC) is connected to the top edge of the septum along the bridge and slopes down toward the face-one for the right side and one for the left side.

The cross-section of this structure looks like a triangle with its apex at the bridge. Separation of the ULCs from the septum often occurs in rhinoplasty, most often as the result of reducing the nasal bridge in the middle one-third of the nose. In effect, this removes the top of the triangular structure created by the ULCs and the septum, causing separation of these structures where they were previously connected.

Unless the connection between the ULCs and septum is recreated (done surgically through placement of cartilage "spreader" grafts and sutures), the ULCs will collapse inward progressively over time. This will lead to pinching of the bridge and internal nasal airflow obstruction. Sometimes only one side will collapse, resulting in an asymmetrically pinched middle one-third. Correction of these problems requires placement of spreader grafts stabilized between the top edge of the septum and ULCs. Asymmetries in this region may be addressed by utilizing spreader grafts which are appropriately varying in width.

Weakness of the side walls of the nasal tip causing pinching and nasal collapse. Some of the most common complaints of the secondary, or revision rhinoplasty patient are those related to weak, unsupported nasal tip side walls. This complication creates a pinched appearance to the tip and may create nasal obstruction. Aggressive reduction or narrowing techniques pf the tip during initial rhinoplasty are likely to create these problems. Patients with thin skin and narrow noses are particularly at risk to develop such complications.

The degree of collapse may vary in severity and typically requires structural cartilage grafting. These grafts can be curved cartilaginous supports placed into the area of maximal side wall weakness. Through the external approach, the grafts are placed into tight pockets which overlap and extend the normal cartilages of the nasal tip and side walls, the lower lateral cartilages (LLC).

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Nostril pinching and retraction

Reduction or narrowing of the tip cartilages may also cause weakness and deformity along the edge of the nostrils as well as nasal airway obstruction problems. Over-elevation of the nasal tip may cause excessive nostril show. Contracture from previous reduction of the lower lateral cartilage may also be evident from the base view of the nose as nostril pinching. Correction of the problems may be accomplished by placement of thin cartilage grafts (alar rim grafts) which may restore support and create a stronger triangular nasal base. These grafts are long, narrow cartilaginous segments which are placed into precise pockets along the nostril rim.

Severe cases of nostril retraction may require the use of composite grafts containing both cartilage and skin in order to push down the elevated nostril. These grafts may be taken from the inner bowl of the external ear.

Nasal tip

Some of the most noticeable nasal deformities caused by rhinoplasty occur in the nasal tip. Tip deformities come in all forms and may result from any of the classes of surgical errors described above. The external rhinoplasty approach in revision of the nasal tip allows for unparalleled ability to correct asymmetries. Asymmetry of the tip may result from problems of unequal excision, suture modification, or cartilage grafting.

Subtle discrepancies may not become evident for several months until the edema resolves. Cartilage irregularities, or "bossae", may form as the result of knuckling or angulation of the lower lateral cartilage and tip grafts as the skin envelope contracts after primary nose surgery. Patients with thin skin and strong cartilage are particularly susceptible to this problem. In the revision rhinoplasty surgery, conservative cartilage trimming, re-doing suture techniques, and/or placement of camouflaging grafts may correct such problems.
The pinched nasal tip results from excessive narrowing of the tip cartilages. The narrowness of the tip may be further complicated by tip side-wall collapse and nostril rim pinching. This unnatural, operated appearance is a sure sign of prior nose surgery. Restoring a natural tip appearance may require reconstruction of the entire tip cartilage system with grafts which rebuild the entire complex.

Over-shortened nose

A short nose deformity is most frequently due to upward malposition of the tip cartilages. This may be the result of poor judgment in the degree of tip elevation created by the surgeon. In other cases, destabilization of the nasal tip cartilage in combination with upward scar contracture creates this unwanted result.

Correction of this deformity may require repositioning of the tip cartilage structures into a lower position. This may be accomplished by pulling the tip cartilages downward, effectively lengthening the nose. Typically, the two lower lateral tip cartilages are freed from each other and repositioned downward through suture fixation onto a stable anchor in the center of the base of the nose. This anchor may be the edge of the septum if it is long enough. In other cases, a strong midline cartilage graft may be used to secure the cartilages. Other cartilage grafts may be placed above the nasal tip in order to push the tip structures downward.

Droopy tip

Maintaining tip position during nose surgery depends on restoring any loss of tip support which occurs during surgery. A variety of surgical maneuvers to the nasal tip and surrounding areas during primary rhinoplasty can significantly compromise nasal tip support. This may lead to gradual loss of tip support, a hanging tip, an overly acute angle between the nose and upper lip, and an under projected, long nose with a rounded polybeak deformity. During revision rhinoplasty surgery, tip position and support may be restored through the use of cartilage grafts which may build strength and size to the tip.

Alar nostril base

One of the most difficult rhinoplasty complications to correct is the overly narrowed nostril alar base. Alar base reduction during primary nose surgery should be performed conservatively with the aim of achieving 60 to 70% of an idealized reduction at the time of primary surgery. Unfortunately, excessive or asymmetric reduction is a common mistake during primary rhinoplasty. Composite grafts of skin and cartilage harvested from the ear work well to correct such deformities. These grafts are inserted into incisions placed at the areas of maximal narrowing. Such grafts are useful also to correct scarred nostril narrowing from previous surgery..

Skin injury

When the skin has been significantly damaged, the revision rhinoplasty surgeon must be exceedingly cautious in manipulating the skin-soft tissue envelope. This problem is often caused by an infected or extruding implant. In such situations, the implant should be removed, the infection controlled with antibiotics, the damaged skin envelope allowed to recover, and the contour restored with replacement cartilage grafting.
If there is any doubt regarding the integrity of the skin, surgery should be delayed to allow full recovery. Blue discoloration or multiple broken blood vessels signify damage and added risk for skin complications. In the worst cases where the soft tissue envelope has already been severely compromised, one should consider staged preliminary repair of the skin prior to any structural nose surgery.

Conclusion

Revision rhinoplasty poses some of the most difficult challenges of facial plastic surgery. The ability to correct these problems is limited by the integrity of the existing structures, the availability of grafting material, and the severity of the individual deformities. In many cases, revision rhinoplasty becomes an operation of reconstruction more than of simple refinement.

The examples cited represent only a fraction of the multitude of potential problems during revision rhinoplasty surgery. In some cases, the cause of the problem may not become clear until the revision surgery. In the face of compromised nasal structures, scarred soft tissue, and a lack of cartilage grafting material, the revision surgeon must be prepared for the worst of scenarios.

Even more than in primary nose surgery, this requires meticulous attention to detail in pre-operative analysis. Thoughtful planning based on this analysis as well as a thorough understanding of the problems often encountered in revision rhinoplasty will maximize the chance of a favorable outcome.